Maxillofacial Trauma: A Clinical Guide

Foreword
Preface
Contents
About the Editors
Part I: Basic Considerations
1: Introduction to Craniomaxillofacial Trauma
1.1 Introduction
1.2 Historical Perspective
1.2.1 Evolution of Diagnostic Imaging
1.3 Epidemiology
1.3.1 Assessment of the Severity of Injury
1.3.2 Prevention
1.3.3 Falls
1.3.4 Road Traffic Accidents
1.3.5 Warfare and Terrorism
1.3.6 Sports Injury
1.4 Conclusion
References
2: Surgical Anatomy of the Face
2.1 Introduction
2.2 Zone I
2.2.1 Frontal Sinus
2.3 Zone II
2.4 Zone III
2.5 Zone IV
2.5.1 Parotid Duct
2.6 Zone V
2.7 Zone VI
2.8 Neck
2.9 Conclusion
References
3: Biomechanics of the Maxillofacial Skeleton
3.1 Introduction
3.2 Bones (Origin, Structure, Composition, and Mechanical Properties)
3.2.1 Origin of Bones of Facial Skeleton
3.2.2 Structure
3.2.3 Composition
3.2.4 Mechanical Properties
3.3 Biomechanics of Mandible and Midface
3.3.1 Buttresses System of Facial Skeleton
3.3.2 Biomechanics of Mandible
3.3.3 Biomechanics of Midface
3.4 Fracture Healing
3.4.1 Indirect/Secondary Bone Healing
3.4.2 Direct/Primary Bone Healing
3.5 Conclusion
References
4: Principles of Osteosynthesis
4.1 Introduction
4.2 Principles of Fracture Management
4.3 Classification of Fixation Techniques (Fig. 4.1)
4.3.1 Internal Fixation
4.3.2 Rigid Fixation
4.4 Compression Osteosynthesis
4.4.1 Static Compression
4.4.2 Dynamic Compression (Pauwells, 1935, 1965)
4.4.3 The Tension Band Principle
4.4.4 Compression with a Plate
4.4.5 Dynamic Compression Plate (DCP) (Perren et al. 1969)
4.4.6 Eccentric Dynamic Compression Plate (EDCP)
4.4.7 Compression with Lag Screws
4.4.8 Position Screws
4.4.9 Compression with a Plate in Combination with a Lag Screw
4.5 Non-rigid Fixation
4.6 Functionally Stable Fixation
4.7 Miniplate Osteosynthesis
4.7.1 Historical Background
4.7.2 Introduction
4.7.3 Ideal Lines of Osteosynthesis of the Mandible (Fig. 4.11)
4.7.4 Technical and Anatomical Considerations of Miniplate Application
4.7.5 Miniplate Specifications
4.7.6 Single and Multiple Fractures
4.7.7 Technical Advantages
4.7.8 Functional Advantages
4.7.9 Disadvantages of Miniplating Osteosynthesis
4.7.10 Miniplate Osteosynthesis for Edentulous Jaw Fracture
4.7.11 Miniplate Osteosynthesis for Mandibular Condyle Fracture
4.7.12 Miniplate Osteosynthesis in the Upper and Midface Region
4.7.13 Microplates
4.8 Load-Bearing Osteosynthesis Vs Load-Sharing Osteosynthesis
4.8.1 Load-Bearing Osteosynthesis
4.8.2 Reconstruction Plates
4.9 Reconstruction Plate with Locking Mechanism
4.10 Load-Sharing Osteosynthesis
4.11 External Fixation
4.11.1 External Fixator Devices
4.12 Maxillomandibular Fixation
4.13 Types of MMF
4.14 Dental Wiring
4.14.1 Direct Interdental Wiring [23]
4.14.1.1 Gilmer’s Wiring
4.14.1.2 Risdon’s Wiring
4.14.1.3 Essig’s Wiring
4.14.2 Indirect Dental Wiring
4.14.2.1 Ivy Eyelet Wiring (Fig. 4.22)
4.15 Hallam Modification (1945) (Fig. 4.23)
4.15.1 Clove Hitch Method (Fig. 4.24)
4.15.1.1 Arch Bars
4.15.1.2 Intermaxillary Fixation Screws
4.15.1.3 IMF with Orthodontic Brackets
4.15.1.4 Hybrid Arch Bars (Fig. 4.29)
4.16 Cap Splints and Gunning Splints
4.16.1 Various Types of Wiring [23]
4.16.2 Per Alveolar Wiring (Fig. 4.31)
4.16.2.1 Circum-Mandibular Wiring (Fig. 4.32)
4.16.2.2 Suspension Wiring (Table 4.3) (Fig. 4.33)
4.17 Splinting
4.17.1 AO/ASIF Recommendation (2012) [16]
4.17.2 Desired Characteristics of a Splint
4.17.3 Types of Splints [26, 27]
4.17.3.1 Rigid Splints
4.17.3.2 Semi-Rigid/Flexible Splints/Non-rigid Splints
4.17.4 Rigid Splints
4.17.4.1 Suture Splints
4.17.4.2 Wire Ligature Splints (Fig. 4.34)
4.17.4.3 Arch Bar Splints
4.17.4.4 Acrylic Splints
4.17.5 Flexible/Non-rigid Splint
4.17.5.1 Composite and Wire Splints
4.17.5.2 Orthodontic Wire and Bracket Splints (Fig. 4.35)
4.17.5.3 Fibre Splints
4.17.5.4 Titanium Trauma Splint (TTS)
4.18 Conclusion
References
5: Basic Introduction to Internal Fixation Devices and Armamentarium
5.1 Introduction
5.2 History
5.3 Bone Plates
5.3.1 Miniplates and Microplates
5.3.2 Lambda Plates
5.3.3 Delta Plate
5.3.4 3D Plate
5.3.5 Titanium Mesh
5.3.6 Orbital Mesh
5.3.7 Locking Plate and Screw System
5.3.8 Reconstruction Plate
5.3.9 THORP Plate (Titanium-Coated Hollow Osseous Integrating Screw and Reconstruction Plate System)
5.4 Bone Screws
5.4.1 Pullout Strength of Screw
5.4.2 Concept of Stress Shielding and Its Effect on Screw Loosening
5.4.3 Lag Screws
5.4.4 Emergency Screws
5.5 Alloy Constituents of Metal Bone Plates and Screws
5.6 Bioresorbable Plate and Screw
5.7 Specialized Armamentarium Used in Craniomaxillofacial Trauma
5.8 Instruments Used for Retraction
5.9 Instruments Used for Bone Reduction
5.9.1 Zygomatic Elevators (Fig. 5.36a)
5.10 Instruments Used for Maxillomandibular Fixation (Fig. 5.37)
5.11 Instruments Used for Fracture Fixation
5.12 Conclusion
References
6: Medicolegal Aspects in Maxillofacial Trauma
6.1 Introduction
6.2 Historical Background
6.3 Medicolegal Case (MLC)
6.4 Manner of Infliction
6.5 Medical Evidence
6.6 Medicolegal Report
6.7 General Guidelines for Intervening a Medicolegal Case
6.8 Medicolegal Examination
6.8.1 Documentation of Clinical Findings
6.9 Importance of Wound Pattern Characteristics [4]
6.10 Admission and Discharge of MLC
6.11 Informed Consent for Trauma
6.11.1 History and Theory of Informed Consent
6.11.2 Valid Consent: Ethical Duty
6.11.3 Informed Consent in Oral and Maxillofacial Surgery
6.11.4 Major Surgery Under General Anaesthesia
6.11.5 Informed Consent and Negligence in Oral and Maxillofacial Surgery
6.11.6 Defence for Non-information
6.11.7 Informed Consent for Clinical Trials and New Techniques
6.11.8 Dentist/Maxillofacial Surgeons as Expert Witnesses
6.11.9 Summon
6.11.10 Definitions
6.11.11 Can a Dental Surgeon/Maxillofacial Surgeon Issue a Death Certificate?
6.11.12 Indemnity/Insurance: General Dental Council (GDC)
6.11.13 Consumer Protection Act (CPA)
6.12 Conclusion
References
7: Perioperative and Anesthetic Considerations in Maxillofacial Trauma
7.1 Introduction
7.2 Emergency Management of Maxillofacial Injuries
7.3 Preanesthetic Evaluation for Elective Maxillofacial Trauma Surgeries
7.4 Preoperative Medication Instruction
7.5 Airway Assessment
7.6 Anesthetic Management for Maxillofacial Surgery
7.6.1 Direct Laryngoscopy and Intubation
7.6.1.1 Types of Endotracheal Tube
7.6.1.2 Video Laryngoscopy
7.6.1.3 Fiberoptic Bronchoscopy (FOB)
7.6.2 Supraglottic Airway Devices (SAD)
7.6.3 Surgical Airway (Cricothyroidotomy and Tracheostomy)
7.6.4 Submental Intubation
7.6.5 Retromolar Intubation
7.6.6 Retrograde Intubation
7.7 Intraoperative Management
7.8 Anesthesia Drugs in Brief
7.9 Extubation and Postoperative Management
7.10 Conclusion
References
Part II: Case Based Discussion
8: Emergency Management of Trauma Patient and General Considerations
8.1 Introduction
8.2 History
8.3 Epidemiology
8.3.1 Trimodal Death Distribution Curve
8.4 Pre-Hospital Management
8.5 Triage
8.6 Multiple and Mass Casualties
8.7 Rapid Assessment of Severity of Injury
8.8 Primary Survey and Resuscitation
8.9 A: Airway Maintenance with Restriction of Cervical Spine Motion
8.10 B: Breathing and Ventilation
8.10.1 Immediate Life-Threatening Chest Injuries Affecting Breathing and Ventilation
8.11 C: Circulation with Hemorrhage Control
8.11.1 Blood Volume and Cardiac Output
8.11.2 Bleeding
8.11.3 Important Life-Threatening Chest Injuries Affecting Circulation
8.12 D: Disability: Neurologic Status
8.12.1 Important Brain Injuries Affecting Neurologic Status
8.13 E: Exposure/Environmental Control
8.13.1 Adjuncts to Primary Survey and Resuscitation
8.13.2 Need for Patient Transfer
8.13.3 Secondary Survey
8.13.4 AMPLE History
8.13.5 Physical Examination
8.13.6 Adjuncts to the Secondary Survey
8.13.7 Importance of Team Work
8.13.8 Records and Legal Consideration
8.14 Conclusion
8.15 Case Discussion
8.16 Case Progression: Initial Assessment
8.16.1 Airway and Breathing
8.16.2 Circulation
8.16.3 Disability and Neurologic Intervention
8.16.4 Exposure and Environment Control
8.17 Adjuncts to Primary Survey
8.18 Case Summary
References
9: Soft Tissue Injuries
9.1 Introduction
9.2 Aetiology
9.3 Classification
9.3.1 Management of Soft Tissue Injuries [4–6]
9.3.2 Animal and Human Bites
9.3.3 Delayed Primary Wound Closure
9.3.4 Supportive Therapy
9.4 Conclusion
9.5 Case Discussion
9.5.1 Chief Complaint and History of Presenting Illness
9.5.2 Clinical Examination
9.5.2.1 General Physical Examination
9.5.2.2 Extraoral Examination
9.5.2.3 Intraoral Examination
9.5.3 Investigations
9.5.4 Diagnosis
9.5.5 Follow-Up
References
10: Dentoalveolar Fractures
10.1 Introduction
10.2 Aetiology
10.3 Mechanism of Injury
10.4 Factors Determining an Impact to Teeth or Jaws
10.5 Peculiarity of Traumatic Aspect in Paediatric Population
10.6 Classification of Dentoalveolar Injuries
10.6.1 Fracture of Mandibular Alveolar Bone was Classified into Four Types by William D. Clark [5]
10.6.2 Diagnosis and Clinical Evaluation
10.6.2.1 History
10.7 Examination
10.7.1 Extraoral Soft Tissues
10.7.2 Intraoral Soft Tissues
10.7.3 Alveolar Bone Fractures
10.7.4 Teeth (Displacement and Mobility)
10.7.5 Radiographic Examination
10.7.6 Management of Dentoalveolar Injuries
10.7.6.1 Emergency/Primary Care
10.7.6.2 Treatment of Dental Injuries
10.8 Management of Crown and Root Fractures in Primary Dentition (Tables 10.1, 10.2 and 10.3)
10.9 Management of Crown and Root Fractures in Permanent Dentition (Tables 10.4, 10.5, 10.6, 10.7, and 10.8)
10.10 Most Commonly Employed Method in Reduction of Dentoalveolar Fractures
10.11 Description of Various Types of Splint
10.11.1 Open Reduction and Use of Microplates
10.12 Conclusion
10.13 Case Discussion
References
11: Introduction to Mandibular Fractures
11.1 Introduction
11.1.1 Anatomy
11.1.2 Embryology
11.2 Incidence and Etiology
11.3 Classification
11.4 Clinical Examination
11.4.1 Initial Assessment
11.4.2 Clinical Features
11.5 Radiological Evaluation
11.6 Surgical Approaches to the Mandible
11.6.1 Approaches Through Existing Laceration
11.6.2 IntraOral Approach
11.6.3 Submandibular Approach
11.6.4 Retromandibular Approach
11.6.5 Preauricular Approach
11.6.6 Endaural Approach
11.6.7 Posterior Auricular Approach
11.6.8 Endoscopic Approach
11.7 Conclusion
References
12: Symphysis, Parasymphysis and Body Fractures
12.1 Introduction
12.2 Classification
12.2.1 Symphysis/Parasymphysis Region
12.2.2 Mandibular Body Region
12.3 Clinical Features
12.3.1 General Signs and Symptoms
12.3.2 Clinical Examination
12.3.2.1 Extraoral Examination
12.3.2.2 Intraoral Examination
12.3.3 Radiographic Examination
12.4 Management
12.4.1 Treatment Methods
12.4.2 Closed Reduction Methods
12.4.3 Arch Bar Fixation Followed by Intermaxillary Fixation (IMF)/Maxillomandibular Fixation (MMF)
12.4.4 Indications
12.4.5 Contraindications
12.4.6 Advantages of MMF
12.4.7 Disadvantages
12.4.8 IMF Screw
12.4.9 External Fixation
12.4.10 Open Reduction Method
12.4.11 Internal Fixation/Osteosynthesis
12.4.11.1 Transosseous Wire Osteosynthesis
12.4.11.2 Plate Osteosynthesis
12.4.12 Symphysis/Parasymphysis Fractures
12.4.13 Mandibular Body Fractures
12.4.14 Tooth in the Line of Fracture
12.4.15 Geriatric Considerations
12.4.16 Paediatric Considerations
12.4.17 Recent Advances
12.4.17.1 Three-Dimensional Miniplates
12.4.17.2 Bioresorbable Plates
12.4.17.3 Patient-Specific Implants (PSI) (Fig. 12.6)
12.4.17.4 Advantages of PSI Over Standard Implants
12.5 Conclusion
12.6 Case Scenario
12.6.1 Case 1: Left Parasymphysis of Mandible #
12.6.1.1 Chief Complaint
12.6.1.2 History of Present Illness (HOPI)
12.6.1.3 Clinical Examination
12.6.1.4 Investigations
12.6.1.5 Diagnosis
12.6.2 Case 2: Right Body of Mandible #
12.6.2.1 Chief Complaint
12.6.2.2 Hopi
12.6.2.3 Clinical Examination
12.6.2.4 Investigations
12.6.2.5 Diagnosis
References
13: Angle and Ramus Fractures
13.1 Introduction
13.1.1 Anatomical Considerations
13.2 Classification
13.2.1 Comprehensive AOCMF Mandibular Fracture Classification System (Cornelius et al. [4])
13.2.1.1 Angle/Ramus Region
Spiessl Classification
13.2.2 Rowe and Williams Classification
13.3 Clinical Features
13.3.1 Extraoral Findings
13.3.2 Intraoral Findings
13.3.3 Radiographic Examination
13.4 Management
13.5 Approaches to Angle Fracture
13.6 Various Fixation Methods of Angle Fracture
13.6.1 Closed Reduction/MMF
13.6.2 Open Reduction with Internal Fixation
13.6.2.1 Various Fixation Methods
Single Plate at Superior Border
Two-Plate Technique
Single-Plate at Inferior Border
Fixation with Lag Screws
Fixation with the Reconstruction Plate
Fixation with DCP and EDCP
Fixation with 3D Plates
Fixation with Bioresorbable Plates
13.7 Consideration of Tooth in the Line of Angle Fracture
13.8 Paediatric Considerations
13.9 Geriatric Considerations
13.10 Conclusion
13.11 Case Discussion
References
14: Condylar Fractures
14.1 Introduction
14.2 Surgical Anatomy of the Condyle
14.3 Aetiology
14.4 Clinical Features
14.5 Diagnostic Aids
14.6 Computerised Tomography Scan (CT) and Cone Beam Computerised Tomography (CBCT)
14.7 Magnetic Resonance Imaging (MRI)
14.8 Computerised Tomographic Angiography (CTA)
14.9 Diagnostic Temporomandibular Joint (TMJ) Arthroscopy
14.10 Classification of Condylar Fracture
14.11 Classification of Condylar Head Fracture (Modification of Classification by He et al. [6])
14.12 Biomechanics of Fractured Condyle
14.13 Management of Fractures of Condyle
14.14 Closed Treatment
14.15 Open Surgical Reduction and Fixation
14.16 Indications for Open Reduction
14.17 Surgical Approaches to Condyle
14.18 Fixation Techniques for Condylar Base and Neck Fractures
14.19 Management of Condylar Head Fractures
14.20 Management of Condylar Fractures in Children
14.21 Associated Other Fractures of Mandible and Face
14.22 Avoidance of Complications of Open Reduction
14.23 Soft Tissue Considerations in Condylar Fractures
14.24 Advances in Condylar Fracture Management
14.25 Conclusion
14.26 Case Discussion
14.26.1 Chief Complaints
14.26.2 Clinical Examination
14.26.3 Radiological Investigations
14.26.4 Treatment
References
15: Introduction to Midface Fractures
15.1 Introduction
15.2 Applied Anatomy of the Midface
15.3 Development of the Midface [6]
15.4 Incidence and Aetiology
15.5 Clinical Examination
15.5.1 Initial Assessment
15.5.1.1 Symptoms
15.5.1.2 Signs
Extraoral
Intraoral
15.6 Radiological Evaluation
15.7 Classification of Midface Fractures
15.7.1 Classification of Midface Fractures Based on Anatomy (According to Rowe and Williams [11])
15.7.1.1 Fractures Sparing Occlusion
Central Region
Lateral Region
15.7.1.2 Fractures Involving Occlusion
15.7.2 Classification According to Manson et al. [12]
15.7.3 Comprehensive AOCMF Classification [13]
15.7.4 Level 2 Midface and Orbital Fracture Classification (Fig. 15.5)
15.8 Management Protocol
15.9 Surgical Approaches to the Midface
15.9.1 Various Approaches to the Midface
15.9.2 Layers of the Scalp (Fig. 15.7)
15.9.3 Layers of the Temporoparietal Region [16] (Fig. 15.8)
15.9.3.1 Temporal Branch of Facial Nerve
15.9.3.2 The Medial Orbit
15.9.3.3 Hemicoronal Approach (Fig. 15.9)
15.9.3.4 Bicoronal Approach (Fig. 15.10)
15.9.3.5 Surgical Technique [16]
15.9.3.6 Modifications
15.9.3.7 Complications
15.10 Al-Kayat-Bramley’s Incision [17]
15.11 Gillies Temporal Incision [17]
15.12 Orbital Approaches
15.12.1 Lower Eyelid Approach
15.12.1.1 Surgical Anatomy [16]
15.12.1.2 Lateral Canthal Tendon
15.12.1.3 Medial Canthal Tendon
15.12.1.4 Types of Dissection
15.12.2 Infraorbital Incision [16]
15.12.2.1 Surgical Technique
15.12.3 Subciliary Incision [17]
15.12.3.1 Surgical Technique
15.12.3.2 Subtarsal Incision [17]
15.12.3.3 Transconjunctival [18]
15.12.3.4 Transcaruncular [18]
15.12.3.5 Lateral Canthotomy
15.12.4 Upper Eyelid Approach
15.12.4.1 Upper Lid Blepharoplasty Incision [17]
15.12.4.2 Medial Crease Incision
15.12.5 Supraorbital Eyebrow Approach
15.12.5.1 Lateral Brow Incision
15.12.5.2 Crow’s Feet Incision [17]
15.12.6 Incisions for Nasoethmoid Fractures (Fig. 15.14)
15.12.6.1 H-Shaped Approach
15.12.6.2 Bilateral Z Incision
15.12.6.3 Midline Vertical Approach
15.12.6.4 W-Shaped Approach
15.12.7 Transoral Approach
15.12.7.1 Maxillary Buccal Sulcus Approach [19]
15.12.7.2 Midface Degloving Incision [19]
15.13 Endoscopic Approach to Midface Trauma
15.14 Conclusion
References
16: Le Fort Fractures
16.1 Introduction
16.1.1 Surgical Anatomy of the Midface
16.2 Classification
16.2.1 Le Fort Classification (1901) [5]
16.2.2 Based on Fracture Level [6]
16.2.3 Based on Fracture Direction (Erich 1942) [6]
16.2.4 Based on the Relationship of the Fracture Line to the Zygoma [6]
16.2.5 Rowe and Williams’ Classification (1985)
16.2.6 Modified Le Fort Classification (Marciani et al. [7])
16.2.7 Classification Based on Localisation of Maxillary Fractures [8]
16.2.8 Classification of Palatal Fractures (Hendrickson et al. [9])
16.3 Le Fort I Fracture
16.3.1 Clinical Features
16.4 Le Fort II Fracture
16.4.1 Clinical Features
16.5 Le Fort III Fracture
16.5.1 Clinical Features
16.6 Investigations
16.6.1 Imaging
16.6.1.1 Plain Radiographs
16.6.1.2 Computed Tomography
16.6.2 Management
16.6.2.1 Consideration of Timing of Repair
16.6.2.2 Key Points to be Considered While Repairing Le Fort Fractures
16.6.3 Treatment Methods
16.7 Methods of Reduction of Le Fort/Maxillary Fractures
16.8 Osteosynthesis/Fixation Methods
16.8.1 Closed Method
16.8.1.1 External Fixation (Mostly Obsolete in Contemporary Practice) [11]
16.8.1.2 Internal Fixation
Internal Skeletal Suspension (Less Preferred in Contemporary Practice)
16.8.2 Open Method
16.8.2.1 Wire Osteosynthesis (Transosseous Wiring) [11]
16.8.2.2 Plate Osteosynthesis (with 2 or 1.5 mm Miniplates and 2 Screws Around Each Side of Fracture Line)
16.8.3 Surgical Approaches
16.8.3.1 Approach to Zygomaticomaxillary Buttress (ZMB) and Nasomaxillary Buttress (NMB)
16.8.3.2 Approach to Frontozygomatic Suture and Lateral Wall of the Orbit (Fig. 16.25)
16.8.3.3 Approach to Infraorbital Region (IOR) (Fig. 16.25)
16.8.3.4 Coronal Approach
16.8.3.5 Through the Existing Laceration
16.9 Flowchart Showing the Sequencing of Treatment (Fig. 16.27)
16.9.1 Post-Operative Care
16.9.2 Special Considerations
16.9.2.1 Paediatric Patients
16.9.2.2 Geriatric Patients
16.10 Recent Evidences
16.11 Conclusion
16.12 Case Discussion
References
17: Zygomaticomaxillary Complex Fractures
17.1 Introduction
17.2 Classifications
17.3 Clinical Features
17.3.1 Paraesthesia
17.3.2 Epistaxis
17.3.3 Crepitation
17.3.4 Displacement of the Palpebral Fissure
17.3.5 Diplopia
17.3.6 Enophthalmos
17.4 Investigations
17.4.1 Specific Lines Are Assessed on the Occipitomental View Called as Campbell’s and McGregor Lines (Fig. 17.1)
17.4.2 Dolan’s and Jacoby’s Lines Also Known as “Elephant’s Facial Skeleton” (Fig. 17.2)
17.4.3 Delbalso’s 4 “S” Criteria
17.4.4 Hot Sites of the Fracture in ZMC
17.5 Management
17.5.1 Five Fundamental Principles
17.5.2 Incision Principles
17.5.3 Number of Points to be Fixed for a Stabilised Fixation
17.5.4 Rationale
17.5.5 Optimum Time
17.5.6 Options for Management
17.5.6.1 Indications for Internal Fixation
17.5.6.2 Objectives of Open Reduction and Fixation of the Zygomatic Maxillary Fractures
17.5.6.3 Indications for Internal Orbital Reconstruction
17.5.6.4 Steps in Treatment
17.5.6.5 Various Approaches of Indirect Reduction of ZMC Fractures
Surgical Approaches for Open Reduction of the ZMC Fractures (Fig. 17.3)
Methods of Fixation Available
Gillies Temporal Approach
Percutaneous Cheek Approach
Lothrop’s Antrostomy
Lateral Eyebrow Approach by Dingman
Keen’s Technique
Outcomes of Treatment
17.6 Complications
17.7 Special Considerations
17.7.1 Zygomatic Complex Fractures in Paediatric Patients
17.7.2 Zygomatic Complex Fractures in Geriatric Patients
17.8 Recent Advances
17.9 Evidence-Based Knowledge
17.10 Conclusion
17.11 Case Discussion 1
17.11.1 Chief Complaint
17.11.2 History of Present Illness
17.11.3 Past Medical History
17.11.4 Clinical Examination
17.11.4.1 Inspection
17.11.4.2 Palpation
17.11.5 Investigations
17.11.6 Treatment
17.12 Case Discussion 2
17.12.1 Chief Complaint
17.12.2 History of Present Illness
17.12.3 Past Medical History
17.12.4 Clinical Examination
17.12.5 Investigations
17.12.6 Treatment
References
18: Naso-Orbito-Ethmoidal Complex Fractures
18.1 Introduction
18.2 Surgical Anatomy
18.2.1 Medial Canthus and the Central Segment
18.3 Classification
18.4 Clinical Examination
18.4.1 Initial Evaluation
18.5 Local Examination
18.5.1 Inspection
18.5.2 Palpation
18.5.3 Clinical Features
18.6 Radiology
18.7 Management
18.7.1 Approaches to NOE Skeleton
18.7.2 Closed Vs Open Reduction
18.7.3 Medial Canthus and Canthopexy
18.7.4 Implants for Internal Fixation
18.7.5 Pediatric and Geriatric Considerations, If Any
18.8 Complications Associated with Upper-Third Facial Fractures
18.9 Advancement in Upper or Complex Facial Fracture Management
18.10 Conclusion
18.11 Case Discussion
18.11.1 Chief Complaints
18.11.2 Clinical Examination (Fig. 18.16a)
18.11.3 Radiology/Diagnosis: CT Scan Reveals (Fig. 18.16b)
18.11.4 Pre-Trauma Photograph for Evaluation of Nasal Projection (Fig. 18.16c)
References
19: Orbital Fractures
19.1 Introduction
19.2 Osteology
19.2.1 Inferior Orbital Fissure (IOF)
19.2.2 Intraorbital Buttress
19.2.3 Posterior Ledge
19.3 Surgical Anatomy
19.3.1 Medial Canthal Ligament (MCL)
19.3.2 Lateral Canthal Ligament
19.3.3 Lacrimal Drainage Apparatus
19.3.4 Intercanthal Distance (ICD)
19.3.5 Safe Surgical Exploration Distances
19.4 Etiopathogenesis
19.4.1 Buckling Theory/Bone Conduction Theory [8]
19.4.2 Hydraulic/Retropulsion Theory [9]
19.4.3 Globe to Wall Theory [10]
19.5 Classification of Orbital Fractures
19.5.1 Single-Wall Fractures
19.5.2 Two-Wall Fractures
19.5.3 Three-Wall Fractures
19.5.4 Based on Anatomical Region
19.6 Classification of Orbital Wall Defect Size [13]
19.6.1 Blowout [14]
19.6.2 Blow-in [15]
19.7 Clinical Features and Evaluation
19.8 Clinical Examination
19.9 Diagnostic Imaging
19.10 Other Modalities
19.11 Assessment of CT Scans
19.11.1 1 cm Rule
19.12 Rationale for Surgical Management
19.12.1 Goals of Surgery
19.12.2 Management
19.12.2.1 Non-Surgical Management
19.12.2.2 Surgical Management
19.12.2.3 Contraindications
19.12.2.4 Time of Surgery
19.13 Incisions for Approach to the Orbital Floor (Fig. 19.16a, b)
19.13.1 Surgical Steps
19.13.2 Treatment Algorithm for Orbital Wall Fractures
19.14 Graft Materials Used for Orbital Floor Reconstruction
19.14.1 Autologous Bone Graft
19.14.2 Post-Operative Assessment
19.15 Complications
19.15.1 Retrobulbar Haemorrhage
19.16 Paediatric Consideration
19.17 Recent Advances
19.18 Conclusion
19.19 Case Scenario
19.19.1 Technique
19.19.2 Glossary
References
20: Frontal Sinus Wall Fractures
20.1 Introduction
20.2 Function
20.3 Epidemiology/Mechanism of Injury
20.4 Classification
20.5 Clinical Features
20.6 Investigations
20.7 Management
20.7.1 Management of Anterior Table Fracture
20.7.2 Posterior Table Fracture
20.7.2.1 Undisplaced or Mildly Displaced Posterior Table Fracture Without NFOT Injury
20.7.2.2 Nasofrontal Outflow Tract (NFOT) Injury Without Significantly Displaced Posterior Table Fracture
20.7.2.3 Displaced Posterior Table Fracture with NFOT Injury
20.7.2.4 Displaced Posterior Table Fracture with Dural Tear/CSF Leak
20.8 Complications of Frontal Sinus Fractures
20.9 Conclusion
20.10 Case Discussion
20.10.1 Chief Complaint
20.10.2 HOPI
20.10.3 Past Medical History
20.10.4 Clinical Examination
20.10.5 Radiological Findings
20.10.6 Other Investigations
20.10.7 Management
References
21: Panfacial Trauma
21.1 Introduction
21.2 Aetiopathogenesis
21.3 Classifications for Severity of Injury
21.4 Initial Evaluation
21.4.1 Concomitant Injuries [13]
21.4.2 Extensive Facial Injuries
21.5 Clinical Features
21.6 Radiological Features
21.7 Management
21.7.1 Importance of Facial Buttresses in Panfacial Trauma [1, 4]
21.7.2 Airway Management [1, 4, 5]
21.7.3 Surgical Approaches [1, 4]
21.7.4 Sequencing in Panfacial Fractures
21.7.4.1 Bottom-Up and Inside-Out Approach [4] (Fig. 21.7)
21.7.4.2 Top-Down and Outside-In Approach [2, 4] (Fig. 21.8)
21.7.5 Soft Tissue Suspension [1, 2, 4]
21.7.6 Timing in Panfacial Trauma Management
21.8 Complications [2]
21.9 Conclusion
21.10 Case Discussion
21.10.1 Case 1
21.10.1.1 Clinical Examination
Extra-Oral Examination (Fig. 21.9a–c)
Intra-Oral Examination (Fig. 21.10)
21.10.1.2 Radiological Diagnosis [4, 5] (Fig. 21.11a, b)
21.10.1.3 Treatment Plan (Fig. 21.12a–g)
21.10.2 Case 2
21.10.2.1 Clinical Examination
Extra-Oral Examination (Fig. 21.13)
Intra-Oral Examination (Fig. 21.14)
21.10.2.2 Radiological Diagnosis [4, 5] (Fig. 21.15a–d)
21.10.2.3 Treatment Plan
References
22: Animal Bite, Firearm and Ballistic Injuries
22.1 Animal Bite Injuries
22.2 Classification
22.3 Management of Animal Bite Injuries
22.3.1 Primary Management
22.3.1.1 Emergency Room Management
22.3.1.2 Basic Wound Care
22.3.1.3 Prophylaxis
22.3.1.4 Antibiotic Prophylaxis
22.4 Specialised Management
22.4.1 Multidisciplinary Approach
22.4.2 Soft Tissue and Hard Tissue Management
22.4.3 Rehabilitation
22.5 Complications
22.6 Recent Advances
22.7 Prevention
22.8 Case Discussion
22.9 Firearm and Ballistic Injuries
22.10 Ballistics
22.11 Firearms
22.12 Ballistics of Missile Injury
22.12.1 Stress Wave
22.12.2 Cavitation
22.12.3 Fragmentation
22.12.4 Shotgun Wounds
22.12.5 Rifle Gun Injuries
22.13 Clinical Features
22.13.1 Anterior Face
22.13.2 Lateral and Posterior Mandible
22.13.3 Midface
22.13.4 Indirect Injuries Caused by the Projectiles
22.13.5 Contamination of Missile Wounds
22.14 Management
22.14.1 Haemorrhage Control
22.15 Neck Penetrating Injuries
22.16 Imaging
22.17 Nutrition
22.18 Operative Procedure
22.19 Documentation
22.20 Case Discussion
22.21 Conclusion
References
23: Complications in Maxillofacial Trauma
23.1 Introduction
23.2 General Complications
23.2.1 Immediate Resuscitative Complications
23.2.2 Airway Obstruction
23.2.3 Complications of Tracheostomy
23.2.4 Acute Hemorrhage, Hypovolemia, and Hypoxia
23.2.5 Electrolytic Imbalance
23.2.6 Nutrition-Related Complications
23.2.7 Associated Cervical Spine and Head Injury
23.3 Local Complications
23.3.1 Soft Tissue Complications
23.3.1.1 Soft Tissue Loss
23.3.1.2 Local Hemorrhage and Hematoma
23.3.1.3 Laryngeal Trauma
23.3.1.4 Muscle Atrophy
23.3.1.5 Hypertrophic Scar, Keloid, and Contracture
23.3.1.6 Oral Incompetence
23.3.2 Ophthalmic Complications
23.3.2.1 Ectropion
23.3.2.2 Entropion
23.3.3 Glandular and Ductal Injury
23.3.3.1 Parotid Gland and Duct Injury
23.3.3.2 Parotid Gland Injury
23.3.3.3 Parotid Duct Injury
23.3.4 Complications of Parotid Gland and Duct Injuries
23.3.4.1 Sialocele
23.3.4.2 Salivary Fistula
23.3.4.3 Nasolacrimal Duct Injury
23.3.4.4 Post-Burn Sequelae of Maxillofacial-Neck Area
23.3.4.5 Delayed Wound Healing
23.3.5 Management of Chronic Wounds [10]
23.3.5.1 Cleaning
23.3.5.2 Debridement
23.3.5.3 Wound Dressing
23.3.5.4 Antibiotics
23.3.5.5 Hyperbaric Oxygen Therapy
23.3.5.6 Ultrasound and Electromagnetic Therapy
23.3.5.7 Negative Pressure Wound Therapy
23.3.5.8 Skin Grafts
23.4 Hard Tissue Complications
23.4.1 Cranial Complications
23.4.2 Immediate Complications
23.4.2.1 Cerebrospinal Fluid Leak and Meningitis
23.4.2.2 Raised Intracranial Pressure
23.4.3 Carotid-Related Injuries
23.4.4 Other Intracranial Complications
23.4.5 Late Complications
23.4.5.1 Post-Severe Head Injury
23.4.5.2 Cranial Vault Deformity
23.4.6 Fronto-Naso-Orbital Complication
23.4.7 Complications Related to Frontal Region
23.4.7.1 Frontal Sinus Fractures
23.4.7.2 Cosmetic Deformity
23.4.8 Complications Related to Nasal Region
23.4.8.1 Septal Hematoma
23.4.8.2 Nasal Deformity
23.4.8.3 Traumatic Telecanthus
23.4.9 Complications Related to Orbital Region
23.4.9.1 Retrobulbar Hematoma
23.4.9.2 Diplopia
23.4.9.3 Enophthalmos
23.4.9.4 Superior Orbital Fissure Syndrome (SOFS)
23.4.9.5 Orbital Apex Syndrome
23.5 Zygomatico-Maxillary Complications
23.5.1 Zygomatic Arch Depression
23.5.2 Altered Sensation/Paresthesia
23.5.3 Maxillary Sinus Infection.
23.5.4 Occlusal Complications
23.6 Maxillary Fracture Complications
23.6.1 Preoperative Complications
23.6.1.1 Airway Obstruction and Hemorrhage
23.6.2 Intraoperative Complications
23.6.2.1 Problems with Reduction and Fixation
23.6.3 Post-Operative Complications
23.6.3.1 Malunion, Nonunion, and Occlusal Complications
23.7 Complications of mandibular fractures
23.7.1 Preoperative Complications
23.7.1.1 Upper Airway Obstruction
23.7.1.2 Hemorrhage and Emphysema
23.7.2 Intraoperative Complications
23.7.2.1 Problems with Reduction and Fixation
23.7.2.2 Problems with Edentulous Atrophic Mandible
23.7.3 Post-Operative Complications
23.7.3.1 Malunion and Nonunion
23.7.3.2 Occlusal Complications
23.7.3.3 Altered Sensation
23.7.4 Temporomandibular Joint-Related Complications
23.8 Nerve Injury
23.8.1 Cranial Nerves I, II, III, IV, and VI
23.8.2 Trigeminal Nerve Injury
23.8.3 Facial Nerve Injury
23.9 Infections
23.9.1 Wound Infection
23.9.2 Post-Traumatic Sinusitis
23.9.3 Space Infections
23.9.4 Osteomyelitis
23.9.5 Dacryocystitis
23.9.6 Cavernous Sinus Thrombosis
23.9.7 Hardware-Related Complications
23.10 Summary
23.11 Case Report
23.11.1 Case Study of a Patient with Severe Post-Burn Contracture of Maxillofacial-Neck Region.
References
24: Rehabilitation
24.1 Introduction
24.2 Surgical or Prosthetic Rehabilitation
24.3 Classification of Maxillofacial Defects
24.3.1 For the Maxilla
24.3.2 For the Mandible
24.3.3 For Midfacial Defect
24.4 Classification of Maxillofacial Prosthesis
24.5 Classification of Maxillofacial Prosthesis (Table 24.1)
24.5.1 Based on the Complexity of Fracture
24.5.2 Based on Its Function
24.5.3 Based on the Anatomical Areas
24.5.4 Based on the Type of Retention
24.5.5 Based on the Type of Fabrication
24.6 Materials Used for Maxillofacial Prosthesis
24.6.1 For Fabrication
24.6.2 Retention of Maxillofacial Prosthesis
24.6.3 Coupling between Implant and Prosthesis Is Individually Discussed with Each Prosthesis
24.6.4 Complications
24.6.5 Types of Extraoral Prosthesis (Table 24.5)
24.6.6 Types of Intraoral Prosthesis (Table 24.5)
24.6.7 Composite Prosthesis (Table 24.5)
24.7 Phases of Maxillofacial Rehabilitation
24.7.1 Paediatric Rehabilitation
24.7.2 Maxillary Rehabilitation
24.7.3 Orbital Rehabilitation
24.7.4 Implants in Paediatric Patients
24.7.5 Geriatric Patient
24.7.5.1 Implants in Geriatric Patient
24.8 Digitalisation in Maxillofacial Rehabilitation
24.9 Upcoming Trends
24.10 Conclusion
24.11 Case Scenario
24.11.1 Clinical Examination
24.11.1.1 Extraoral
24.11.1.2 Intraoral
24.11.1.3 Diagnosis
24.11.1.4 Treatment
References